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Table 4 Evidence table for accepted randomized controlled trials assessing the effectiveness of manual therapy for musculoskeletal disorders of the upper and lower extremities

From: The effectiveness of manual therapy for the management of musculoskeletal disorders of the upper and lower extremities: a systematic review by the Ontario Protocol for Traffic Injury Management (OPTIMa) Collaboration

Author(s), Year Subjects and Setting; Number (n) Enrolled Interventions; Number (n) of Subjects Comparisons; Number (n) of Subjects Follow-up Outcomes Key Findings
Bergman et al., 2004 [51] Participants (=18 y.o) recruited from general practices in Groningen, the Netherlands. Manual therapy and usual care: Usual care: 12 (immediately post-intervention), 26 and 52 weeks Primary outcomes: Patient-perceived recovery (manual therapy and usual care vs. usual care):
Case definition: Pain of variable duration between the neck and elbow at rest or during movement of the upper arm; physical examination confirming shoulder symptoms and dysfunction in the cervicothoracic spine and ribs with accompanying pain or restricted movement (n=150) Manual therapy (up to 6 sessions over 12 weeks) by physiotherapists: manipulations and mobilization to the cervical spine, upper thoracic spine, and adjacent ribs. Usual care (information, advice, and therapy) as outlined by the Dutch College of General Self-perceived recovery (7point Likert scale; recovered = “completely recovered” or “very much improved”) Proportion of participants reporting themselves ‘completely recovered’ or ‘verymuch improved’ (reference group: usual care)a:
Usual care (information, advice, and therapy) according to the Dutch College of General Practitioners provided by GPs: delivered following same protocol as in manual therapy and usual care group (n=71) Cure rate (self-report of shoulder symptom improvement to a point where they are no longer inconvenient) 12 weeks: RR 2.0 (95% CI 1.2, 3.4)
26 weeks: RR 1.2 (95% CI 0.8, 1.7)
Practitioners provided by GPs:
52 weeks: RR 1.5 (95% 1.0, 2.2)
Weeks 1–2: information about the nature and course of shoulder symptoms, advice on daily activities, prescription for oral analgesics or NSAIDs if necessary.
Proportion of participants reporting symptom improvement to the point where they are no longer inconvenienta:
12 weeks: RR 1.4 (95% CI 0.9, 2.0)
26 weeks: RR 1.2 (95% CI 0.9, 1.8)
52 weeks: RR 1.4 (95% CI 1.0, 1.9)
Difference in mean change (manual therapy and usual care – usual care):
Severity of main complaint (0–10)
12 weeks: 1.5 (95% CI 0.5, 2.5)
26 weeks: 1.2 (95% CI 0.2, 2.2)
52 weeks: 1.4 (95% CI 0.4, 2.4)
Shoulder disability (0–100)
12 weeks: 8.5 (95% CI -2.0, 18.9)
26 weeks: 12.7 (95% CI 1.3, 24.1)
52 weeks: 6.9 (95% CI -3.5, 20.7)
General health (3 point scale)
No difference.
Weeks 3–4: extension of prescription medication if necessary. Secondary outcomes: severity of main complaint (NRS, 0–10); functional disability (SDQ, 0–100), quality of life (EuroQol, 5 items scored using 3-point ordinal scale, -1=worst; 1=best).
Weeks 5–6: Up to 3 subacromial or glenohumeral corticosteroid injections (40mg triamcinolone acetonide with or without 10mg lidocaine)
Weeks 6–12: Physiotherapy shoulder exercises, massage and passive physical modalities were considered. (n=79)
Cook et al., 2014 [52] Patients (=18 y.o.) attending outpatient clinical/academic centers in the USA or South Africa. Shoulder and neck treatment by physiotherapist: Shoulder treatment by physiotherapist: Immediately post-intervention [mean 56.1 days (SD 55.0)] Primary outcome: Disability (QuickDASH, 0–100) Difference in mean change (shoulder and neck treatment – shoulder treatment) a:
Secondary outcome: Pain (NRS, 0–10), patient satisfaction and adaptation to symptoms (PASS, acceptable = unlikely to seek further treatment, unacceptable = likely to seek further treatment) Disability (QuickDASH 0–100):
Case definition: Shoulder impingement syndrome (mean duration 11.7 weeks) with: 1) pain or dysfunction with overhead activities and active shoulder movements; 2) positive Neer/ Hawkins-Kennedy test; 3) onset =12 months; 4) painful arc; 5) baseline pain =2/10 (n=74)
Neck treatment (duration and frequency of treatment determined by the physiotherapist): Grade III posterior-anterior mobilization (3 x 30 oscillations) to stiffest or most painful segments in the cervical spine or to the C5-C6, or C6-C7 segments on the same side of shoulder impingement if joint findings were absent. Pragmatically delivered multimodal program of care including manual therapy stretching, isotonic strengthening, and restoration of normative movement. (n=36)
Post-intervention: 5.3 (95% CI -3.0, 13.6)
Pain (NRS 0–10)
Post-intervention: 0.5 (95% CI -0.6, 1.6)
No difference in the proportion of participants considering their state ‘acceptable’ (unlikely to seek further treatment) a:
Post-intervention: RR 0.92 (95% CI 0.73, 1.15)
Multimodal shoulder care: manual therapy, stretching, isotonic strengthening, and restoration of normative movement. (n=38) No adverse events reported.
Cleland et al., 2013 [53] Patients (16–60 y.o.) with inversion ankle sprain presenting to physical therapy clinics in Colorado. MTEX: HEP: 4 weeks (immediately post-intervention) and 6 months Primary outcome: Disability (FAAM ADL subscale; 0–100). Differences in mean change (MTEX-HEP):
Manual therapy by physical therapist (2 x 30 minute sessions per week for 4 weeks): Grade I-IV mobilization (grade selected by therapist /patient tolerance) to the proximal tibiofibular joint, distal tibiofibular joint, talocrural joint, and subtalar joint. Home exercises (daily): Instruction by a physical therapist (1 x 30 minute session per week for 4 weeks): same exercises as MTEX group FAAM ADL (0–100):
Home exercises (daily): mobilizing exercises for the foot and ankle, gentle strengthening exercises, resistive-band exercises, 1-leg standing activities, standing on balance board, and weight-bearing functional activities; program progressed by physical therapist as indicated
Advice to continue with activities that did not increase symptoms and avoid activities that aggravate symptoms.
Education on ice, compression, and elevation. (n=37)
1 month: 11.7 (95% CI 7.4, 16.1)
6 months: 6.2 (95% CI 0.98, 11.5)
Secondary outcomes: Disability (FAAM sports subscale; 0–100); Function (LEFS; 0–80); Pain (NRS; 0–10); global improvement (-7 to +7); recurrence FAAM sports (0–100):
Case definition: grade 1 or 2 inversion ankle sprain as defined by the West Point Ankle Sprain Grading System; no restriction in days since injury; NRS = 3/10 in last week; negative Ottawa ankle rules. (n=74) Advice to continue with activities that did not increase symptoms and avoid activities that aggravate symptoms 1 month: 13.3 (95% CI 8.0, 18.6)
6 months: 7.2 (95% CI 2.6, 11.8)
LEFS (0–80):
1 month: 12.8 (95% CI 9.1, 16.5)
6 months: 8.1 (95% CI 4.1, 12.1)
Education on ice, compression, and elevation. (n=37) NRS (0–10):
1 month: 1.2 (95% CI 0.9, 1.5)
6 months: 0.47 (95% CI 0.05, 0.90)
Global Improvement:
Statistically significant difference in favor of MTEX at 1 and 6 months (p<0.001).
No difference in the proportion of participants reporting recurrence of their injury at 6 months:
RR 0.6 (95% CI 0.15; 2.33)
No adverse events were reported.
  1. Acronyms: ADL Activities of Daily Living, FAAM Foot and Ankle Ability Measure, GP General Practitioner, HEP Home exercise program, LEFS Lower Extremity Functional Scale, MTEX Manual therapy and exercise program, NRS Numeric Rating Scale, RR Relative Risk, SDQ Shoulder Disability Questionnaire, QuickDASH the Quick Disabilities of the Arm, Shoulder, and Hand
  2. arecalculated data from study